NURSING PROCESS RECORD

FIRST PRIORITY

MEDICAL DIAGNOSIS: G1P0 PU 40 5/7 weeks AOG by LMP, Cephalic in Labor

NANDA Nursing Diagnosis: Ineffective breastfeeding related to maternal fatigue and insufficient parental knowledge regarding breastfeeding
techniques
NANDA Definition: Difficulty feeding milk from the breast, which may compromise nutritional status of the infant/child.
CUES/Defining NURSING OUTCOME NURSING INTERVENTIONS CLASSIFICATION EVALUATION
Characteristics CLASSIFICATION (NOC) (NIC)
SUBJECTIVE DATA: NOC 1. Knowledge NIC 1. [5244] Lactation Counselling Day 1:
“Gamay lang nga gatas Breastfeeding Activities: NOC 1. Knowledge Breastfeeding
gagawas sa akong totoy”  Determine mother’s desire and motivation to
[180010] Signs of adequate breastfeed as well as perception of [180010] Signs of adequate milk
“Maglisod sab ko og milk supply breastfeeding supply
patotoy”  Instruct on infant’s cues
[180005] Proper technique in  Instruct on various feeding positions 2 – Limited knowledge
OBJECTIVE DATA: attaching infant to the breast  Discuss the techniques to avoid or minimize
 Pale in appearance engorgement and associated discomfort [180005] Proper technique in
 Weak 1- No knowledge  Discuss strategies aimed at optimizing milk attaching infant to the breast
 Delay in milk 2- Limited knowledge supply
production 3- Moderate knowledge 2 – Limited knowledge
 Insufficient emptying 4- Substantial knowledge
of each breast for 5- Extensive knowledge NIC 2. [6710] Attachment promotion NOC 2. Breastfeeding establishment:
feeding  Encourage mother to breastfeed, if Maternal
 Perceived inadequate appropriate
milk supply NOC 2. Breastfeeding [100101] comfort of position
 Provide adequate breastfeeding education
ABNORMAL LABS: Establishment: Maternal during nursing
and support, if appropriate
 HCT: 27.9%
 Instruct parent on infant cues for feeding
 Hgb:8.8 g/dl [100101] Comfort of position 2 – Slightly adequate
(e.g. rooting, sucking on fingers, crying)
 Blood loss not during nursing
indicated

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[101102] Support breast using
“C” hold
[100120] Fluid intake of mother
NIC 3. [2080] Fluid Management
NOC 3. Breastfeeding
establishment: Infant
[100006] Nursing a minimum
of 5-10 minutes per breast
[2000015] Stop to burp infant
at frequent intervals
1- Not adequate
2- Slightly adequate
3- Moderately adequate
4- Substantially adequate
5- Totally adequate
[101102] support breast using “C”
hold
2 – Slightly adequate
 Promote oral intake [100120] Fluid intake of mother
 Maintain accurate intake and output record
. 3 – Moderately adequate
NOC 3. Breastfeeding establishment:
Infant
[100006] Nursing a minimum of 5-
10 minutes per breast
1 – Not adequate
[2000015] Stop to burp infant at
frequent intervals
2- Slightly adequate
Observations:
 Unable to determine presence
of milk on breasts
 Inadequate fluid intake
 Breastfeeding duration is short
to empty each breast.
 Burping is less observed.
Day 2
NOC 1. Knowledge Breastfeeding
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[180010] Signs of adequate milk
supply

4 – Substantial knowledge

[180005] Proper technique in

attaching infant to the breast

4 – Substantial knowledge

NOC 2. Breastfeeding establishment:

Maternal

[100101] Comfort of position

during nursing

4 – Substantially adequate

[101102] Support breast using “C”

hold

3 – moderately adequate

[100120] Fluid intake of mother

4 – Substantially adequate

NOC 3 Breastfeeding establishment:

Infant

[100006] Nursing a minimum of 5-

10 minutes per breast

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4 – Substantially adequate

[2000015] Stop to burp infant at

frequent intervals

4 – Substantially adequate

Observations:
 Fluid intake increased.
 Burps infant after each
feeding.
 Able to demonstrate C hold.
 Determines presence of milk
on breasts.
 Determined presence of milk
in breast.
 Breastfeeding duration is
enough to empty each breast.

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SECOND PRIORITY

MEDICAL DIAGNOSIS: G1P0 PU 40 5/7 weeks AOG by LMP, Cephalic in Labor

NANDA Nursing Diagnosis: Fatigue related to physiological factors such as anemia, pregnancy, inadequate sleep, labor and delivery.
NANDA Definition: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at the usual level.

CUES/Defining NURSING OUTCOME NURSING INTERVENTIONS CLASSIFICATION (NIC) EVALUATION

Characteristics CLASSIFICATION (NOC)
SUBJECTIVE DATA: NOC 1. Fatigue Level NIC 1. [0180] Energy Management DAY 1:
“Luya akong paminaw [000701]-Exhaustion Activities: FATIGUE LEVEL
maong di ko kapadede 5- NONE  Encourage verbalization of feelings about
usahay” limitations.
4- MILD [000701]-Exhaustion
 Monitor nutritional intake to ensure adequate
OBJECTIVE DATA: 3- MODERATE energy resources.
 Pale in appearance 2- SUBSTANTIAL  Monitor/record patient’s sleep pattern an number 3-MODERATE
 Weak 1-SEVERE of sleep hours.
 Impaired ability to  Monitor location and nature of discomfort or pain [000720]-SLEEP QUALITY
maintain usual [000720]-Sleep Quality during movement or activity.
physical activity [000723]-Hematocrit  Assist patient in assigning priority to activities to 3-Moderately Compromised
 Increased in rest accommodate energy levels.
5- Not compromised
requirement  Encourage the patient to choose activities that
 Insufficient energy 4- Mildly compromised gradually build endurance. [000723]-HEMATOCRIT
 Tiredness 3- Moderately compromised  Promote bedrest/activity limitation (e.g., increase
ABNORMAL LABS: 2- Substantially compromised number of rest period) with protected rest times 2- Substantially Compromised
 Hct: 27.9% 1-Severely compromised of choice.  Decreased Hgb and Hct
 Hgb:8.8 g/dl  Offer aids to promote sleep (e.g., music, from normal value
medications).  Encouraged to state
 Assist patient to sit on side of bed (dangle), if feelings.
unable to transfer or walk.  Patient has difficulty
 Assist with regular physical activities (e.g., sleeping.
ambulation, transfers, turning, and personal  Awakens at night during
care), as needed. sleep.

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 Encourage physical activity (e.g., ambulation,  Unable to perform ADL
performance of activities of daily living) due to feeling of being
consistent with patient’s energy resources. tired.
 Monitor patient’s oxygen response (e.g., pulse
rate, cardiac rhythm, and respiratory rate) to DAY 2:
self-care or nursing activities.
 Instruct patient/significant other on fatigue, its [000701]-Exhaustion
common symptoms ad latent recurrences.
 Instruct patient/significant other to recognize
signs and symptoms of fatigue that require 4-MILD
reduction in activity.
 Instruct patient/significant other to notify health [000720]-SLEEP QUALITY
care provider if signs and symptoms of fatigue
persist. 4-Mildy Compromised

[000723]-HEMATOCRIT

4- Mildly Compromised

Observations:
 Hgb: 9.3 g/dl
 Hct: 28.0 %
 Able to ambulate with less
pain
 Sleeps well

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THIRD PRIORITY

MEDICAL DIAGNOSIS: G1P0 PU 40 5/7 weeks AOG by LMP, Cephalic, In Labor

NANDA DIAGNOSIS: Acute pain related to surgical incision secondary to episiotomy wound
NANDA DEFINITION: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage (International Association for the Study of Pain); sudden or
slow onset of any intensity from mild to severe with an anticipated or predictable end, and with a
duration of less than 3 months.
CUE’s/ Defining NURSING OUTCOMES NURSING INTERVENTIONS EVALUATION
characteristics CLASSIFICATION (NOC) CLASSIFICATIONS (NIC)

SUBJECTIVE DATA: NOC 1. Pain level NIC 1. Pain management DAY 1:

 “Sakit ang katung [210201] Reported pain  Observe nonverbal cues of NOC 1. Pain level
gitahian “ [210208] Restlessness discomfort.
 Rated pain 5, in the [210201] Reported pain
1-Severe  Provide accurate information to
scale of 1-10, in which
10 is the most severe 2-Substantial promote family’s knowledge of and 3- Moderate
3- Moderate response to pain experience.
OBJECTIVE DATA: 4-Mild  Promote adequate sleep and rest to [210208] Restlessness
5-None reduce pain.
 Pain 3- Moderate
 Weak appearance  Determine the impact the pain
NOC2. Maternal status :
 Limited ROM postpartum experience on quality of life. NOC2. Maternal status :
 Difficulty in ambulating postpartum
 Minimal movement [251110] – Perineal healing
with guarding [251125] – Incisional pain [251110] Perineal healing
behaviour 1- Severe deviation from 3 - Moderate deviation from
 With median normal range normal range
episiotomy 2- Substantial deviation from
normal range
[251125] Incisional pain
3- Moderate deviation from
normal range 3 - Moderate deviation from
4- Mild deviation from normal normal range

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 range
5- No deviation from normal Observations:
range  With median episiotomy
 Lochia rubra, moderate in
amount
 Difficulty in ambulating
 Rated pain as 5/10, 10 as
the most severe
 Tends to move around a lot

DAY 2
NOC 1. Pain level

[210201] Reported pain

4-Mild

[210208] Restlessness

4-Mild

NOC2. Maternal status :

postpartum

[251110] Perineal healing

2 - Mild deviation from
normal range
[251125] Incisional pain
2 - Mild deviation from
normal range

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Observations:
 Limited ROM
 Minimal movement with
guarding behaviour
 Lochia Rubra, moderate in
amount
 Rated pain 2 in the scale of
1-10
 More relax, tends to move
less than day 1.

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